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Transcripts-8/7/00
Women's Health With Dr Susan Hoch. M.D.
(WARNING: Part of this transcript
contains conversation about sexual issues)
This chat went from formal using chat
protocol to an informal open discussion. Little editing was done.
DrSusan> Hi everyone.
skeeter> hello
debbie> hello dr
InsightHostKJ> Ok men check! Anyone male in here?
dd> nope
debbie> not me
InsightHostKJ> How ya doing Dr Susan?
Melanie> Hi extremer
DrSusan> Doing fine. It's a swamp here in Philadelphia.
InsightHostKJ> Here too Dr Susan
skeeter> pain in arm and left shoulder for 3 years all tests showed nothing..pain only comes at night
DrSusan> So does everyone have their hair in curlers, are we ready to talk Arthritis for Women?
InsightHostKJ> Skeeter..slow down!
InsightHostKJ> Got my jammies on!
Melanie> We are ready! lol
skeeter> oh i am sorry
InsightHostKJ> Dr Susan..you want to try this informal? Or go with Q's?
DrSusan> Whatever.
InsightHostKJ> Alright..let's try it informal....
debbie> dr. susan-do you have any advice for me- i found out 3 weeks ago that i am in the beginning stages of ra
skeeter> what do we do...can we ask questions?
InsightHostKJ> K...topic is Women and Arthritis...
DrSusan> See a rheumatologist! Get on a DMARD - disease modifying agent.
skeeter> pain in left arm and sjpulder for 3 years nothing showed up on all tests and x-rays...only hurts at night...comes and goes can't lay on my left side in bed
InsightHostKJ> As women with arthritis we face some special problems that the guys don't have
DrSusan> The shoulder is a large joint. Is the pain on the top, on the front or on the side? If it is on the side and you can't lie on it, it might be a subacromial bursitits.
skeeter> it is son the back upper left hand side and sometimes my forearm aches
DrSusan> That can be treated by a steroid inbjection. A bursiitis should not limit the range of motion of the shoulder. Do you have difficulty putting your bra on?
dd> how big a factor does heredity play in OA?
skeeter> i can lift my arm up i can still do all my work..just comes and goes...i seem to have it more than not
skeeter> no not all
DrSusan> Sounds more like bursitis to me than soulder joint pathology.
DrSusan> Now, heredity and OA.
DrSusan> This is particularly true for women.
dd> how early can onset be in OA?
DrSusan> If your Mom has gnarled handsfrom osteoarthritis, look out. It may very well be in thecards (and genes) for you.
nsightHostKJ> OK.....this ain't gonna work! Too many questions at once. Please type a ? if you have a question and wait until you are called on to ask it
DrSusan> Knee osteoarthritis has a heredity component as well with other factors being obesity as well as use - i.e. people who work on their knees get worse OA than people who don;t.
dd> gee thanks! Actually, both my mom and her mom have it.....my mom is 50...my son has JRA....
InsightHostKJ> So if there is a history of OA....is there anything we can do to try and prevent it?
DrSusan> For knee OA, lose weight, strengthen the quadriceps muscle.
DrSusan> Learn joint protective strategies for hands, knees etc.
DrSusan> I also prescribe glucosamine and chondroitin sulfate although the jury is still out on whether they are truly disease modifying.
InsightHostKJ> Melanine..go ahead with your question
Midge> Hi I have had RA for 5 years on MTx celebrex & started pred in April.Finally releif.I have beenasked to participate in a gold study for 1 year am abit timid as I was on a study for Trocade which had to be finished early.Any suggestions?
DrSusan> Do you have to be on a study to get your meds paid for? If not, have you considered adding Enbrel or Remicade to the methotrexate and trying to get off the Prednisone.
Melanie> We have been discussing night sweats and HRT on message boards. What do you think about this versus menopause for us 40ish women?
DrSusan> Now, what about hormones ladies?
Melanie> Are night sweats pretty normal or should we consider HRT?
InsightHostKJ> Should we be taking them if we are menopausal?
Melanie> normal with RA?
DrSusan> HRT is a big decision. It depends on what disease you haveand your other risk factors.
InsightHostKJ> What risk factors should we be concerned with?
DrSusan> For example, if you have RA, you have increased risk for cardiovascular disease. It is not yet clear that estrogen or HRT have beneficial effects on the heart.
debbie> i have been on premarin for 19 years i just ask to be put on cenestin
Melanie> Any recommendations if you choose not to pursue HRT to cope with night sweats?
DrSusan> On the other hand, if you have RA, you are at increased risk for osteoporosis and even more so if you are on prednisone. And estrogen is a good drug for the bones.
DrSusan> However, there are other good drugs for the bones such as Fosamax or Actonel which are not hormones.
DrSusan> If you have a family or personal history of breast cance, estrogen is out but Evista might be a good idea for thebones. However, it won't help with hot flashes.
DrSusan> If the problem is just hot flashes, you might consider trying a Clonidine patch.
DrSusan> It's an antihypertensive drug - if your pressure is low, it might be a problem but if you also have high blood pressure, this could be a twofer.
deb> Can you describe joint protective stategies? I have hyper extended joints along with fibro. at least that's the latest theory.LOL
DrSusan> Joint protection is usually taught by physical and occupational therapists. They teach rest, appropriate exercise, splinting and can advise you on all sorts of wonderful gadgets.
SueM> Am I right in assuming all this info is for both RA and OA?
DrSusan> Yup, and not for lupus.
DrSusan> We sdon't know for sure whether postmenopausal estrogen replacement worsens lupus.
Donna> what do you do when you still have hot flashs at 72?
DrSusan> There is a multicenter N.I.H. funded trial called the SELENA trial to look at the very issues of whether estrogen is good orbad for lupus and whether it causes flares. I do not at this time use estrogen in lupus patients.
DrSusan> Again, if you are still having hot flashes at 72, whether they need treatment or not depends on how bad they are for you, what the rest of your medical history isand which risks you are willing to assume.
Meli> ok, on the other end of the spectrum here... can fibro or arthur cause your menstrual cycles to get weird?
DrSusan> I guess the first thing I would think about would be checking the thyroid. There is a lot of thyroid disease in patients with RA.
DrSusan> In addition, many patients with fibromyalgia have thyroid problems.
Meli> got the fibro... kinda wondered if that would play a part in it
DrSusan> Active disease, in particular, active lupus or RA can certainly alter your cycle.
DrSusan> In addition, it seems like a lot of my fibromyalgia patients have endometriosis - which obviously can give painful periodsand strange cycles.
InsightHostKJ> I've heard the same thing from a lot of RAers....wonder if there is a connection between edometriosis and RA?
DrSusan> Stress can also affect your menstrual cycle and what is morestressful than the pain of a chronic rheumatic disease.
DrSusan> KJ, I don't know about an endo-RA connection - it's an interesting thought and line of research.
InsightHostKJ> would be interesting to find out!
skeeter> what are the symtoms of bursitis please...does the pain come and go?
DrSusan> Pain, not limitation of motion.
snickers> I am a 30year old diagnosed with RA since 37, recently my rheumatologist went to another city, and the new doc i was assigned to wants to run a Hepatitis C test since I have never had one ran. I have been with my husband monogamously since I was 17 and my arthritis is controlled with plaquenel. my Rheumatoid Factory was three hundered and something, as well having nodules, is this test necessary. Is this really necessary
DrSusan> In my opinion, yes. Let me tell you why. Hepatitis C arthritis can look just like RA. Hepatitis C is a contraindication to durgs like methotrexate and Arava.
DrSusan> You can get hepatitis C from blood exposure - so if you have been transfused, particularly before 1991, you are at risk.
DrSusan> People from certain countries such as South Korean, Asia, Italy, Spain among others have a high incidence of hepatitis C. Other people at risk are those who are exposed to blood - nurses, firemen, police officers, phlebotomists, doctors etc.
DrSusan> Obviously people who share needles are at risk.
DrSusan> It's actually harder than either HIV or hepatitis B to get from sexual exposure but it is possible. Finally there is about 6%% vertical transmission - that is from mother to child - much less than with HIV or hepatitis B.
DrSusan> So, if you have what looks like RA and are going on methotrexate or Arava, I would check hep studies first.
DrSusan> Are your liver enzymes normal?
InsightHostKJ> so anyone with RA should be checked for Hep C?
DrSusan> Pre methotrexate or Arava.
InsightHostKJ> okay
DrSusan> Or if they have a risk factor for hep C or abnormal liver function tests.
DrSusan> I don't check people without risk, with normal liver tests before I put them on plaquenil or asulfidine or minocycline.
deb> Have had a number of thyroid tests. all o.k. But seem to flare when period is about to start. It's like the fibro doesn't affect my period, just the opposite. Any correlation and why?
DrSusan> No answers deb. I hear this flare before the period a lot, especially in lupus patients. I wonder if there are changes in sleep prior to the period.
DrSusan> In addition, there are clearly all sorts of hypothalamic and pituitary changes in fibromyalgia and the pituitary is involved in stimulating the ovaries.
deb> definite problems even w/ 50 mgs of trazadone as far as sleep
DrSusan> So perhaps the hormones drive a sleep disturbance which intensifies the fibromyalgia.
DrSusan> Maybe you need to work on improving sleep.
deb> any suggestions other than traz.
DrSusan> Lots.
DrSusan> 1. The simple stuff sleep hygiene
DrSusan> For example - don;t work in your bedroom, watch tv in your bedroom, etc. Just use it for sleep.
deb> I'm all ears
DrSusan> Make it dark, comfy - try silk sheets, flannel sheets etc. Comfortable nightwear. Soft music or white noise - like ocean tapes.
Meli> so I take it that my sleeping on the couch in the living room is prolly not a good thing...
DrSusan> No caffeine or other stimulants.
DrSusan> Yup.
DrSusan> Many patients with fibromyalgia have a sleep apnea component.
deb> so far I do every thing but the tapes
DrSusan> If you snore or wake up gasping for breath, get asleep study. You may need a CPAP mask.
DrSusan> Then, there are meds and there are a whole host of meds.
DrSusan> For example, there are short acting hypnotics like Ambien and Sonata.
DrSusan> There are muscle relaxants that make people sleepy like Flexeril, Soma, Zanaflex.
DrSusan> There are SSRI drugs like Trazadone, Remeron, and tricyclics like Elavil.
deb> is 50 mgs of traz ahigh dose?
DrSusan> If there are neurologic issues, one of my favorite meds is Neurontin (gabapentin) which makes many people sleepy.
DrSusan> And then there are thinks like herbal teas, hot milk, etc.ZZZZZZZ
DrSusan> 50 mg of trazs not necessarily a high dose.
JR> Is there any connection between Enbrel and changes in the menstrual cycle, short or olong term
DrSusan> Not that I have seen reported yet. But remember, we have only about 3 year followup on Enbrel patients.
cathy-cow> i am 30 years old and i have ra, dignerative disc deasease and soastic para paralisis. it seems that i just keep getting worse. everytime i ture around i have yet another problem. is this becouse of all my problems combined? right now i am having major problem with my nerves in the spine. the spastic para parilisis affects mainly my right side.i was told that the spastic para parilisis was caused by a stroke in the womb and i just had a tia that put me in that i keep getting worse
DrSusan> Wow, cathy - that's a lot to handle.
InsightHostKJ> i'll say
cathy-cow> why do i keep getting worse ids it all my problems combines?
cathy-cow> my spine has totally collapsed
DrSusan> Why are you having TIAs? Do you have diabetes, are you hypertensive, do you have a heart rhythm problem? Do you smoke? Do you have a anticardioli[pin antibody? All these are risk factors for TIA.
cathy-cow> no i have none of those
DrSusan> Why has your spine collapsed? Do you also have osteoporosis? Or do you have spinal stenosis?
cathy-cow> they have not yet found out why i have those tias
DrSusan> Are you on anticoagulation?
cathy-cow> no i have severs digernative disc deaseazxe
cathy-cow> i was my dr took me off
DrSusan> Why?
cathy-cow> i had problems with the drug
cathy-cow> i have no imune system left
DrSusan> Are you seeing a neurologist for the TIAs/ They are not a rheumatic problem.
cathy-cow> i was but i have no insurance so they would not see me anymore
DrSusan> There are also several ways to anticoagulate people including aspirin, coumadin, Plavix and heparin.
DrSusan> Are you on disability?
cathy-cow> i take celebrex-prevacecid-paxil-evista-
DrSusan> It sounds like you might qualify for disability which will get you health insurance. It doesn't sound as if someone so ill could be able to work.
cathy-cow> no i am still trying- for 5 years now
DrSusan> Get a lawyer and appeal.
cathy-cow> i also had endometrosis
cathy-cow> i have one now
DrSusan> Endometriosis is not a diabling condition generally according to Social Security guidelines but disc disease and TIAs should.
cathy-cow> i know thank you
DrSusan> How about some women's type questions - we've done hormones, periods - how about sex, positions, lubrication etc.
Tra> Thanks, KJ. Doc, I've just started on Minocycline. How long until I can expect to wait until it "kicks in"? How will I know if it's working?
InsightHostKJ> I agree with Dr Susan
DrSusan> Tra - Minocycline often will take a long time to kick in - 6 to 9 months but you should note decreased swelling, less morning stiffness, and less pain. Lab tests such as sedimentation rate and CRP improve.
DrSusan> What do you agree with me about KJ?
InsightHostKJ> Women's issues only for the rest of the chat!
snickers> As I said, I am 30 and I have totally lost my sex drive,, how do i get it back?
DrSusan> Pain is not an aphrodesiac.
InsightHostKJ> LOL no kidding!
DrSusan> If you have Sjogren's, vaginal dryness may make things worse.
DrSusan> There are a number of useful products for lubrication wsuch as Astroglide or KJ jelly.
snickers> no, just to tired to care if I have it or not.
InsightHostKJ> KJ Jelly? LMAO
Melanie> LOL
deb> lol
DrSusan> You can rub it gently on your significant other. Sorry KJ, KY jelly.LOL
Donna> ROFL
InsightHostKJ> snickers it is hard to get in the mood!
DrSusan> Regarding pain, I recommend that my patients try a nice hot bath when they are in the mood and take adequate pain medication beforehand.
DrSusan> Ask your doc for pain med to take before sex. Most docs don't think to ask patients about this and most patients don't ask.
InsightHostKJ> or take the bath with him before hand
DrSusan> If you are a middle aged woman who is menoopausal, a little testosterone may be a wonderful adjunct.
InsightHostKJ> What are some other ways the rest of you get in the mood? Just throw out your suggestions
DrSusan> There is an estrogen replacement with testosterone called Estratest. Ask your gynecologist about it.
Melanie> Partner makes a difference. If they are nurturing person who is sharing with you as opposed to taking from you, it makes a difference.
InsightHostKJ> very true Melanie
JR> Getting the kids to bed early, in theri own beds
DrSusan> Right, if they don;t understand your arthritis and pain, it's hard to be in the mood.
InsightHostKJ> LOL JR..that helps!
DrSusan> Take a nap, light candles or incense if that turns you on, mood music.
deb> Having some quiet time to myself to unwind first and then advance to the sharing stuff!
sassy> Married 25 years, we spend 15 minutes each night, telling each other why we fell in love and why we are still in love
DrSusan> Sounds wonderful.
InsightHostKJ> great idea deb!
Tra> that's sweet!
Donna> wonderful sassy
Marsha> wow sassy...that's great!
Melanie> romantic sassy.
Melanie> Did it take 24 years to get him to do that?
deb> sassy I think I'm jealous
sassy> If we are apart, we have a time to call, never missed a night
InsightHostKJ> finding a comfortable position is difficult
Marsha> That's great, sassy....you're both lucky to have each other....
sassy> Yes, we know
marilyn> PUTTING A PILLOW UNDER MY HIPS HELPS ME NOT TO HURT AS MUCH
DrSusan> But there are all kinds of positions. In addition, there are other kinds of sex besides vaginal intercourse - thank you President Clinton.
marilyn> oops, darn caps
InsightHostKJ> LOL Dr Susan
deb> lmao
InsightHostKJ> but when your jaw is flaring that is difficult too!
deb> Amen1
JR> lol, but I don't think Monica has RA
Melanie> lol
InsightHostKJ> sex toys are wonderful too....make is easier on both partners sometimes
Melanie> I think you have to pick your time too. Make sure its your optimal time
DrSusan> Seriously though, there is a spectrum of sexual activity and with proper preparation and pain medications, patients should be able to express themselves sexually.
sassy> what was your sex drive before the ra
JR> Unfortuantely night, often the only free time , is not optimal because of fatigue
Melanie> I agree JR
InsightHostKJ> and early mornings are out due to stiffness...
DrSusan> Its important to be able to talk with your partner about what he/she likes and tell him/her openly what you like.
deb> All pain meds make me sleepy. what are alternatives?
snickers> my sex drive was large, at least 4 times a week, now maybe twice a month. I am just too tired and orgasms are hard to acheive.
DrSusan> Get a baby sitter for a weekend afternoon.
Melanie> Nooners?!
JR> Where do you say you are going. lol. Do you kick them out
DrSusan> Deb, even extra strength Tylenol!
DrSusan> Depends on the age - maybe a sitter can take them to a movie.
InsightHostKJ> And sometimes sneaking to a hotel room in the middle of the afternoon makes it feel more special
Melanie> Taking care of grownup business, JR (depending on how old they are).
deb> Tylenol doesn't even take the edge off sometimes. And can't pain meds affect orgasms?
DrSusan> Obviously orgasm is a complicated entity.
InsightHostKJ> yes it is Dr Susan!
DrSusan> Other meds, in particular some of the SSRI drugs like Prozac, Paxil, etc can make women anorgasmic.
deb> complicated yes but nice to have once in a blue moon
InsightHostKJ> for me, you can forget orgasm during intercourse....i'm usually too concerned with my hips hurting....but oral sex or mastrubation will work
DrSusan> It is important to be comfortable to discuss this side effect with your doc if you are having it.
InsightHostKJ> just have to find what works for you
DrSusan> Right on KJ, as usual.
Melanie> Creativity is the bottom line. If you love someone and want to share that closeness, you can work together to achieve it. Even some pain drugs give you a wonderful floaty feeling that enhances sex.
InsightHostKJ> so true Melanie
I agree Melanie
Melanie> I don't like sex on demand - with or without RA.
InsightHostKJ> or a margarita if you are not on mtx
DrSusan> Be open with your partner as well. It may be that he/she is afraid of hurting you.
InsightHostKJ> thats a big problem in my house Dr Susan
Melanie> Here too
InsightHostKJ> he wont touch me...I always have to be the agressor
DrSusan> Then you need to reinforce the positive - say things like I love it when you......
InsightHostKJ> I do...
Melanie> that's a good idea
sassy> Talk to him, let him know where you are and what you want
DrSusan> In addition, while mutual orgasm is wonderful, sometimes only one partner may achieve orgasm at a time.
DrSusan> That is still okay.
InsightHostKJ> as long as I get one I don't care when! LOL
Melanie> lol
DrSusan> Or how! There are many ways to accomplish that goal with two loving committed individuals.
InsightHostKJ> and ya know....there is nothing wrong with one having one alone if thats what works for you
Melanie> true enough. Your body responds to stimuli, whatever it is.
DrSusan> And for people not currently in a relationship, having one alone is better than not having one in my book. Orgasm raises endorphin levels which are natural pain meds.
Melanie> Well, sack time is surely going to increase! lol
sassy> Ah, that is why I feel so good aftewards
InsightHostKJ> LOL Melanie
InsightHostKJ> Yes Sassy...it is true
DrSusan> And for many people, holding, kissing, cuddling even without orgasm are wonderful to do.
InsightHostKJ> very goood point Dr Susan
Melanie> I have noticed that many of us with RA were caretakers of parents before diagnosis. Seems like the nurturing, caring part from someone else to me is the best part.
deb> have to agree with that
InsightHostKJ> It's a big part anyways Melanie for me
sassy> Am still caretaker of Mother and Daughter, not as good as orgasm
snickers> besides the regular pap, and mamogram, are there any other test that patients with autoimmune diseases should have yearly?
Melanie> probably what helps keep you going, sassy
DrSusan> Women over 50 need a TSH yearly. Patients with RA, SLE have a higher risk of autoimmune thyroid disease, so I check TSH yearly.
DrSusan> In addition, RA predisposes to osteoporosis.
DrSusan> Steroids cause bone loss.
DrSusan> So if you are on steroids or have been on steroids, you need a bone density study (DXA).
InsightHostKJ> how often for the DEXA?
deb> gosh! look at the time! guess it's time to get some extra pillows girls. Talk to you later:)
InsightHostKJ> night Deb! Have FUN!
Melanie> lol Nite Deb
deb> :):)
DrSusan> At perimenopause, I think it is a good idea to get a DXA if you are not on steroids but have rheumatic diseases. Medicare unfortunately will only pay for a DXA for women at age 65 but I think for many of my patients, it needs to be done sooner.
InsightHostKJ> what about somone like me....35....steriods for 3 years?
Melanie> Dr. Susan if doc identifies pitting in bones, is that osteoporosis?
DrSusan> Other general heatlh things are the same for men and women - they are checks of cholesterol and triglycerides - remember that they rise after menopause.
DrSusan> KJ, I'd get a DXA if I were you.
marilyn> have to go, thanks KJ and Dr.Susan
InsightHostKJ> k...will do
snickers> Thanks Doc Susan, I appreciate the info and advice, gonna go see if I can get a (rise) outta my man. goodnight, lol
InsightHostKJ> ok not go..lol
DrSusan> By the time you see osteoporosis on an xray, you have lost about 50%% of the calcium. A DXA is a better test.
InsightHostKJ> LOL Snickers...good night
DrSusan> Good luck snickers and have fun.
InsightHostKJ> Before anyone else leaves...does anyone object to me posting the transcript?
SueM> Not Me
marilyn> I'm leaving but i am sleeping alone tonight :(
Meli> no probs
Melanie> No, we have no secrets (any more). lol
InsightHostKJ> awww marilyn
Tra> not I
sassy> none
marilyn> no
InsightHostKJ> Great! thanks girls!
DrSusan> No, I volunteered for this. LOL
InsightHostKJ> LOL Dr Susan
SueM> What a thing to volunteer for
InsightHostKJ> Thanks a million once again Dr Susan...you are so good to us!
Melanie> I really appreciate it, Dr. Susan.
DrSusan> It was a blast, as usual.
Tra> Thank you Dr. Susan!!
DrSusan> But the old man is calling. LOL
Melanie> lol
Meli> thanks dr susan
InsightHostKJ> Have fun Dr Susan! LOL
If you didn't get to ask Dr. Susan a question you can always send it to her via experts@arthritisinsight.com
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